Provider Demographics
NPI:1407887391
Name:MILES, DEREK (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:MILES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 E SUNFLOWER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2830
Mailing Address - Country:US
Mailing Address - Phone:662-846-9990
Mailing Address - Fax:662-846-5444
Practice Address - Street 1:907 E SUNFLOWER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2830
Practice Address - Country:US
Practice Address - Phone:662-846-9990
Practice Address - Fax:662-846-5444
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17441208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016081Medicaid
MS0126078Medicaid
MS0126078Medicaid